If your hospital, healthcare organization, or credentials verification organization (CVO) has a delegation agreement with a commercial payer for primary source verification (PSV), you know to expect an audit at least annually. After all, data accuracy and quality are paramount in the worlds of provider credentialing and payer enrollment.

What audits typically cover

Commercial payer audits, or reviews (the informal version), can focus on many aspects of PSV and credentialing of physicians and advanced practice professionals. These include:

  • general policies and procedures regarding data handling
  • roster quality and accuracy
  • adherence to accreditor or certifying body standards
  • security and technology
  • other factors depending on the delagator/delegatee relationship and contract

Timing and legal boundaries

Audits occur at regularly scheduled intervals with the timing and procedures usually spelled out in the delegation contract, or they can be done at random. Triggers of unscheduled commercial insurance payer audits can range widely. For example, a payer analysis showing that a provider’s or group’s data represents an outlier when compared with others could spark an audit. In addition, frequent errors, upcoming contract renegotiation, changes in payer policies, or complaints by any party can also be contributing factors.

Regardless, audits must follow state law and regulatory guidelines. There are differences among regions and states regarding rules and regulations, so if needed healthcare organizations or health plans should seek legal guidance from an entity with expertise in the relevant locale early in the payer audit process. State medical societies also may prove useful for aiding in the commercial payer audit process.

Repeated negative outcomes due to errors or omissions can result in a range of problems, from penalties to contract termination. Above all, avoid the traps by employing a mindset of constant readiness and by maximizing the use of your contract software to stay on track.

Tips for success

Here, we offer 10 tips from the pros at symplrCVO who have guided their clients through a delegation audit or two (or 100).

  1. Regularly review your formalized credentialing policies and procedures. Ensure that they’re up to date, reflect changes the organization has made, and remain in line with the accrediting agency of the health plan.
  2. Suggest that desktop audits be performed within the same month for all delegated relationships to minimize disruption.
  3. Ensure that primary sources meet the accepted standard. Note that not every website is PSV acceptable. You may need to prove your work; keep documentation that your source meets the standard.
  4. Ensure that every provider application is signed and dated. Know the acceptable time frame for a signature. Consider the use of a “true” digital signature. NCQA standards allow for digital and electronic signatures. Many medical credentialing software programs allow for e-signature, whether for contracts, forms, letters, certificates, or other official documentation.
  5. Report any organizational changes (e.g., ownership change) on a timely basis.
  6. Be ready to demonstrate that your organization has a system for ongoing sanctions monitoring. You must show how you maintain and monitor your providers.
  7. Maintain a documented system for the collection of expirables.
  8. Determine whether or not you need an actual copy of any given document. In many cases, you don’t. Be ready to cite and demonstrate this to your auditor.
  9. Use national databases to regularly validate provider data, doing regular clean-up work to maintain accuracy.
  10. Create your own audit process in-house to ensure regular compliance.

Have tips of your own? Share them with us and we’ll happily spread the word.

Considering entering a delegation agreement?

If your organization seeks information about how establish a delegated relationship, the process usually follows a few typical steps you can learn about here.